Provider Demographics
NPI:1306287289
Name:ROESCH, STEFANI L (RD)
Entity type:Individual
Prefix:MS
First Name:STEFANI
Middle Name:L
Last Name:ROESCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MRS
Other - First Name:STEFANI
Other - Middle Name:L
Other - Last Name:GRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:8532 KELSO DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646-4502
Mailing Address - Country:US
Mailing Address - Phone:714-323-2522
Mailing Address - Fax:
Practice Address - Street 1:8532 KELSO DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92646-4502
Practice Address - Country:US
Practice Address - Phone:714-323-2522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL717909133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered